The OTA s Guide to Documentation Writing SOAP Notes 5th Edition by Marie Morreale Otr 9781040138342 1040138349

The OTA s Guide to Documentation Writing SOAP Notes 5th Edition Marie Morreale Otr – Ebook Instant Download/Delivery ISBN(s): 9781638220367,1638220360, 9781040138342, 1040138349

Product details:

• ISBN 10: 1040138349
• ISBN 13: 9781040138342
• Author:  Marie Morreale Otr

The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same easy-to-read format from previous editions to aid OTAs in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice. Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout the text. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language. Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes, and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions. New in the Fifth Edition: Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documents Updated information to meet Medicare Part B and other third-party payer requirements Revised clinical terminology on par with current trends Added examples from emerging practice areas Expanded tables along with new worksheets and learning activities Included with the text are online supplemental materials for faculty use in the classroom, this includes: access to supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process.

Table contents:

Chapter 1 Documenting the Occupational Therapy Process
Chapter 2 The Health Record
Chapter 3 Billing and Reimbursement
Chapter 4 Using Professional Terminology
Chapter 5 Avoiding Common Documentation Mistakes
Chapter 6 Writing the “S”—Subjective
Chapter 7 Writing the “O”—Objective
Chapter 8 Tips for Writing a Better “O”
Chapter 9 Writing the “A”—Assessment
Chapter 10 Writing the “P”—Plan
Chapter 11 Documenting Special Situations
Chapter 12 Improving Observation Skills and Refining Your Note
Chapter 13 Making Good Notes Even Better
Chapter 14 Evaluation and Intervention Planning
Chapter 15 Goals and Interventions
Chapter 16 Documenting Different Stages of Intervention
Chapter 17 Documentation in Different Practice Settings
Chapter 18 Examples of Different Kinds of Notes

People also search:

soap note documentation example

how to write a proper soap note

the ota’s guide to documentation

the ota’s guide to documentation writing soap notes

ota guide to documentation pdf